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HIUS 3182 04-20-2010 **Final Exam due May 6th at 12:00pm. We get it next Thursday?** Health Care Reform and International Comparison Watergate inspires new Nixon health care push? Kennedy?s revised bill includes private intermediaries: compromise Economy and wider politics undermine legislation through the 1970s Carter: Hospital Cost Control Kennedy: continued push for reform 1980: The dream shall never die?? Compromise and policymaking Health care reform elsewhere: how did the process work? UK, France, Canada There was a push towards Health care reform in early 70s was stalled because there were too many factions that eliminated compromise There was a lack of urgency and a degree of disinterest from the public at large Nixon wins ?72 election, but Watergate scandal becomes defining political issue of the decade Watergate has a peculiar effect: initially it actually pushes it forward. For Nixon, the issue is one that he had a position on (didn?t think it was perfect). Wanted to get health care done because it could prove that despite the scandal, he could get things done, still be the president (doesn?t work?) Nixon makes health care reform one of the primary planks of social reform that he is pursuing. Nixon: 1. Comprehensive Health insurance Plan (employer Mandate) 2. Assisted Health Insurance Plans:: state coverage contracts with insurers CHIP plan: relies heavily on employer use. Voluntary, but not really. 2. Basically writing federal subsidies for states to write contracts with private insurers to cover the poor and high risk areas of the market that don?t have access to private insurance Kennedy-Mills Plan (counter Nixon plan): national health insurance but with private intermediaries and cost-sharing Includes copayments and deductibles. Consumers are going to have to share some of the cost of their own health care. Wanted to start shedding the light on cost issues Will allow the private insurers to act as intermediaries These proposals still provokes the AMA; the Kennedy-Mills Plan loose the labor unions Unions hadn?t been consulted, didn?t like the accommodations made to the private sector Preferred the purely public health security plan Legislation derailed by: Watergate Scandal: Nixon Resignation Nixon?s leadership destroyed, attention is distracted? doesn?t happen Allows the AMA to maneuver to stall the bill, unions still pushing against bill too Wilbur Mills scandal, fall 1974 Great reputation GONE (found with Argentinean ?dancer? Fannie Fox) Does manage to win re-election, but as soon as Fannie Fox goes on stage again, Mills shows up at her show? which is the end He?s discredited and striped of his chairmanship Economy falls: Ford focuses on economy, inflation As we move into the mid 70s there is a high inflation Problem: there is no one to replace the leadership of health care reform Mills had been working on a compromise bill between Kennedy-Mills and CHIP/HIP plans By 1975 with Mills out of the picture, everything falls apart, especially with the economy in a recession and inflation going through the roof Through the 70s, health care has become a significant sector of the economy, and was a leading contributor to the inflation rate Carter?s bill gets killed in the House Kennedy still wants to take up national health care again By 1978, Kennedy begins pushing for focus on health care again Another compromise moving away from the vision of government as sole insurer By 79, had picked up Nixon?s idea of employer mandate Kennedy has to address the cost problems himself, acknowledging that pure government run health care is not financially feasible Leads to Edward Kennedy running against Carter for D-nomination Carter drafts bill for health care reform that would only kick in if certain economic conditions are met; Kennedy doesn?t endorse it, foreign affairs undermine it? As we move into the 1980s Edward Kennedy is challenging from the left, undercutting the president Kennedy?s campaign was very serious, hurts Carter?s base of support badly that he needed against Ronald Regan Kennedy and Carter both lose to Regan By 1980, the ?dream? hadn?t died, but the ground had shifted and the idea had been compromised; conditions had pushed it into the realm that no longer seemed feasible Led to debate amongst Democrats about whether the compromises had conceded too much T.R Reed?s book is valuable in setting out comparisons between other countries and the US, but it?s not very historical Vital question; ignoring the history can lead to flawed conceptions of how the US got to where we are now All of the systems depended on the context of the conditions in the country Most did not result in complete overhaul of existing systems, but they BUILT on existing structures United Kingdom: Lloyd George and health care Key context for expansion: fully fledged socialized medicine, a system in which hospitals and doctors work for the government emerged with Britain?s experience in WWII. In late ?30s, British government prepared for massive air attacks on its cities (began evacuation of children and others into the countryside) This creates pressure on health care facilities The receiving areas of the evacuation, population explodes; and in the cities, millions of casualties were expected Out of necessity, government set up national subsidies medical program Found most of major hospital facilities are inadequate and outdated; needed more labs and specialized equipment Ministry builds hundreds of hospitals and clinics around the country, treating millions of civilians and military causalities Government takes on the costs of treatment, managing spaces in the overall system Doctors receive government salaries Many of the private hospitals were simply destroyed; many doctors were close to financial ruin. Government steps in to help with costs None of the expansion had anything to do with political ideology, it was just to keep the system working during the war Sir William Beveridge Report 1942: Commissioned by wartime coalition government Proposal for complete postwar social insurance and welfare system Including national care Question: insurance or will it encompass entire system? Beveridge report dominates post-War policy Winston Churchill, head of wartime coalition endorsed Beveridge?s Report Supports national health insurance Opposes full-scale nationalization Loses postwar election Labor government: creates National Health Service, 1946 The new system born in the war actually improved health (not looking at wartime causalities) By 1946, under the new Labor government, national health service implemented Doctors are not very happy The NHS is not the product of ideology or deliberate policy process, it?s simply a conservative creation developed on tested, practical means that protected existing services. Evolved naturally rather than radical transformation No other country has adopted the British system because they came to universalize health care under entirely different circumstances France President Charles de Gaulle wondering how to provide adequate health care for postwar France System did not have any true insurance trials At the time 75% of population paid cash for medical care Before the war, the one alternative was a series of collective insurance funds organized by large manufacturers or fraternal societies; imposed as (tax) rather than premiums De Gualle expands the existing payroll tax funded private insurance system to cover all people. In 1960s self-employed added Today, French system uses payroll tax insurance, through 144 NOT for profit insurance funds to provide health care service System has highest customer satisfaction, lower mortality, lower cost Ranked as best health care system in the world Private system is expanded for eventual universal coverage Canada, showing the same patterns, but fascinating because there are a number of broad similarities to the United States (federalist political system, different environments across the country, and doctors were paid on a fee-per-service basis) Similarity: the strong Federalist system; authority reserved to the Provinces Difference: wider form of government: parliamentary rather than presidential system Their ?constitution? gives Provinces the sole power of overlooking hospitals and health matters Provincial governments determine health system; decentralization of authority By 1940, areas that were heavily dependent on agriculture and mining were quite poor In 1914, Saskatchewan began retaining a general practitioner to a township In 1916, the a Health Services board was officially established, with townships employing doctors Local system derived from constitutional authority Tommy Douglas, Saskatchewan provincial premier, at opening of University of Saskatchewan Hospital, 1955 Emerges from the political system based on agriculture on socialism Douglas crafts North America?s first universal hospital insurance plan Set up cap of overall spending that Province would pay for hospitals Uniform accounting system One of Canada?s worst Provinces were able to implement universal insurance without federal subsidies In 1957, the federal government moves to make this viable for all Provinces Stipulates that if a majority of the Provinces, representing the majority of the population would use this system, the federal government would pay 50% of the costs for the maintenance of this program Parliamentary system means ONE party has almost complete control Means less chance of bills getting bottled up in commission Coalitions can be formed with minor parties to get things done By 1961, all Provinces had universal hospital plans in place Process repeats itself with Woodrow Lloyd to try and get physicians fees covered CMA fights (with aid of AMA) the bill, saying doctors and patients will lose all choice? Bill passes Doctors stage a three day strike, back down, doctor?s income rises, coverage expands to entire population of Saskatchewan, leading the 1966 federalization of the system There is no single health care system, but 10 Provincial systems Point: in Canada, the system evolves through experiments through Provincial level This overall picture brings us back to original question on compromises bringing health care in the US away from universal health care system Bill today builds national health insurance around mixed public-private system that has evolved in the US Summary US health care reform fails in the 1970s: Competing proposals, weak coalitions Missed opportunity Events (Watergate, stagflation) Lack of public consensus Gradual modification of liberal goals towards reform of existing system? Corresponds with how reform happened elsewhere; systems built on what came before

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